STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
CITRUS MEMORIAL HOSPITAL, )
)
Petitioner, )
vs. ) CASE NO. 88-0386
)
DEPARTMENT OF HEALTH AND )
REHABILITATIVE SERVICES, )
)
Respondent. )
and )
)
COMMUNITY CARE SYSTEMS, INC. ) d/b/a COMMUNITY CARE OF CITRUS COUNTY )
)
Intervenor. )
)
RECOMMENDED ORDER
Notice was provided and on February 13, 14 and 22, 1989, in Tallahassee, Florida, a formal hearing was conducted by Charles C. Adams, Hearing Officer, Division of Administrative Hearings. Authority for the conduct of the hearing may be found in Section 120.57(1), Florida Statutes.
APPEARANCES
For Petitioner: Stephen K. Boone, Esquire
Boone, Boone, Klingbeil Boone & Roberts, P.A.
1001 Avenida Del Circo
P. O. Box 1596 Venice, Florida 34284
For Respondent: Stephen M. Presnell, Esquire
Macfarlane, Ferguson, Allison & Kelly
Post Office Box 82 Tallahassee, Florida 32302
For Intervenors: James C. Hauser, Esquire
Joy Heath Thomas, Esquire Messer, Vickers, Caparello,
French, & Madsen, P.A.
P. O. Box 1876 Tallahassee, Florida 32302
STATEMENT OF THE ISSUES
The issues concern the question of the entitlement of Petitioner to the grant of a certificate of need (CON) to provide home health services in District III.
PRELIMINARY MATTERS
This recommended order is being entered following a review of the transcript filed on March 17, 1989. The exhibits have been considered as well as proposed recommended orders filed on April 3, 1989. A discussion of the fact proposals submitted by the parties is made in an Appendix to the recommended order.
FINDINGS OF FACT
On December 15, 1986, Petitioner made application for a certificate of need (CON) to provide home health services in Citrus County, Florida. That application was denied by Respondent on December 14, 1987.
The basis for denial as set out in Respondent's State Agency Action Report (SAAR) was to the effect that there was no demonstrated need when resort was made to the methodology suggested by the North Central Florida Health Planning Council in its 1986 District III Health Plan. (At that time Respondent did not have a methodology for determining need). It was felt that some advantage might be gained in serving the needs of underserved groups; however, there was limited information to demonstrate that existing home health agencies in the county could not meet the demands for service. Finally, it was stated that the referral agreement between Petitioner, as a source of clients from its hospital operation, and Intervenor as an existing home health care provider, to include use of Petitioner's employees in the provision of care, care which was as "hi-tech", as Petitioner could provide, was sufficient.
Following the application denial, Petitioner filed a timely request for formal hearing under the authority set forth in Section 120.57(1), Florida Statutes.
On February 17, 1988, Intervenor was allowed to intervene.
Given that the Respondent did not have a rule methodology in place to consider this application when first filed or at the point in time where the case was referred to the Division of Administrative Hearings for consideration, on May 12, 1988, Respondent moved, unopposed, to have the case returned to the agency to await the promulgation of a new home health rule. The motion was granted.
On September 12, 1988, the new rule became effective as Rule 10- 5.011(1)(d), Florida Administrative Code. Which provided as follows:
(d) Medicare Certified Home Health Agencies.
Definitions.
Home Health Agency. A home health
agency is defined as a Medicare certified home health agency in accordance with subsection 381.702(10), F.S.
Home Health Services. Home Health Services are defined in accordance with subsection 400.462(3), F.S.
Home Health Services Provider. For the purpose of this rule, a home health services provider is defined as the person or corporate
entity to which the certificate of need or license is issued.
District. District means a service district of the department as established in subsection 20.19(5), F.S.
Service Area. A certificate of need
for the establishment of a home health agency shall authorize a home health services provider to locate a home health agency and serve persons anywhere within the district for which the certificate of need is awarded.
Planning Horizon. The planning horizon is the anticipated time frame within which the agency is expected to be licensed. The planning horizon for applications submitted between January 1 and June 30 of each year, shall be July of the following year; the planning horizon for applications submitted between July 1 and December 31 of each year shall be January of the year following the year subsequent to the application deadline.
Approved Home Health Agency. For the purpose of this rule, an approved home health agency is defined as a new agency within the district which holds a valid certificate of need and has not been licensed by the department one moth prior to the publication date of the semi-annual fixed need pool. Persons or corporations who do not operate Medicare certified home health agency in the district and are the holder of one or more certificate of need approvals within the same district, shall only be counted as one approval. Persons or corporations who do operate a Medicare certified home health agency in the district and are also the holder of a certificate of need approval for the same district, shall not be counted in the inventory of approved agencies.
Quality of Care. Home health agencies regulated under this rule shall meet the minimum of care standards contained in HRS rules 10D-68, F.A.C.
Need Methodology.
The establishment of a home health agency by a provider who does not currently operate a Medicare certified home health agency in a district, shall require a certificate of need for the operation of a Medicare certified home health agency in the district. Applications for home health agencies shall be reviewed against all applicable statutory and related rule criteria. Applications for home health
agencies shall not normally be approved unless a need is indicated in accordance with the formula under paragraph 3. The establishment
of additional Medicare certified home health agencies, additional offices, mail drops, or any other physical presence by a Medicare certified home health services provider within the same district is not subject to a certificate of need.
The need for the establishment of a new home health agency within the HRS district shall be determined twice a year.
The net need for new Medicare home health agencies in each HRS district is calculated as follows:
HHNN =
((PHHV - AHHV)/CEAS) - AHH
Where:
HHNN equals the Medicare certified home health agency net need.
PHHV equals the projected number of home health agency visits for the respective district and planning horizon. The projected number of home health agency visits is calculated by multiplying the number of home
health visits per 1000 population 65 years and over provided by the Medicare certified agencies in the district for the most recent year for which data available, by the projected population 65 years and over for the respective district. The population projections shall be based on the population projects issued by the Executive Office of the Governor available to the department 1 month prior to the publication date of the semi- annual fixed pool.
AHHV equals the actual number of home health agency visits provided by all
Medicare certified home health agencies in the district based on cost report data obtained from Medicare Intermediaries for the most recent year available to the department 1 month prior to the publication date of the semi-annual fixed need pool as specified in Rule 10-5.008(2), F.A.C.
CEAS is the cost efficient agency
size in numbers of visits at which economy of scale is achieved according to the data available to the department. If the fraction (PHHV - AHHV)/CEAS is .5 or exceeds .5, the fraction shall be rounded upward to the nearest whole number.
CEAS shall be updated by the
department annually and shall be determined by the department according to the following methodology:
Rank all agencies by visit size, excluding hospital-based agencies.
calculate the average cost for all visits for each remaining agency.
Calculate the mean visit cost for all agencies, excluding hospital-based agencies, and two standard deviations from the mean for the remaining agencies.
Eliminate agencies with average visit costs at or exceeding two standard deviations above and below the mean visit cost from further calculations.
Array remaining agencies by visit size from low to high, and sort agencies into 4 groupings by visit size containing an equal or similar number of agencies, and calculate the mean cost for each groupings.
Calculate the percentage reduction, if any, in mean visit cost for each grouping as compared to the previous grouping. Identify the agency size groupings which have a mean visit cost reduction of 5 percent or more compared to the mean visit cost of the previous groupings.
Select the agency size grouping for which the last 5 percent or more reduction in mean visit cost is achieved prior to a grouping for which a less than 5 percent reduction is achieved as compared to the previous grouping and determine the median agency size for this grouping rounded to the
nearest thousand. This agency size is defined as CEAS.
AHH equals the number of approved home health agencies in the district.
Preference shall be given to applicants proposing to provide home health care services to indigent persons and Medicaid patients.
Preference shall be given to applicants proposing a comprehensive range of home health services if it is determined by the department that certain types of services are unavailable or that there is a shortage of certain types of home health service.
Preference shall be given to applicants proposing to provide home health services and establish a physical presence underserved areas of the district.
Data Reporting Requirements. Home health agencies regulated under this rule
shall provide the following information to the department or its designee. The information shall be provided for the same reporting period covered by the annual cost reports submitted to the Medicare Intermediaries, and shall be submitted to the department or its designee at the same time the annual cost report is submitted to the Medicare Intermediary.
The total number of patients served
less than 65 years of age and 65 years of age
and over by county of residence.
The total number of visits provided by type of service.
The total number of patients served by payment source including Medicaid, Medicare, and uncompensated care.
As can be seen, this rule considers the need question district-wide as opposed to a county-by-county analysis in effect at the time of application by Petitioner. District III, which contains Citrus County, has fifteen other counties.
The rule in its text is not found to be applicable per se to this application, although its underlying concepts arguably have an influence on the case outcome. While the Petitioner and Respondent urge that the rule does-have retroactive effect and the Intervenor disagrees, all parties acknowledge the logistical awkwardness of trying to employ the rule's terms in a literal sense. In fact, the rule cannot be used as it is written, for reasons to be explained and in any event neither of the proponents have exercised its terms in exact detail.
When Respondent reviewed the application using a modified version of the new rule in the interest of what Respondent believed to be an equitable treatment of pending home health applicants who had waited for the rule to be enacted, it changed its position from one of recommended denial to recommended grant of the CON.
The case was returned to the Division of Administrative Hearings and upon motion by the Intervenor, as granted, the Petitioner updated its application on December 5, 1988. This lead to the hearing on the dates previously described
The updated information was provided to the other parties in this case. It was not given to the local health council for further review by that organization.
Petitioner is a public not-for-profit healthcare organization created by state law. The hospital is governed by a Board of Trustees appointed by the Governor of the State of Florida. The proposed home health agency would be owned and operated by Petitioner. It treats indigent and Medicaid patients and other medically underserved groups. The hospital's mission is to serve the residents of the community regardless of their ability to pay. This approach would be continued in home health care.
Petitioner provides high quality patient care and this could be expected to continue if a CON for home health care was granted.
The quality assurance plan and mechanisms in place at Petitioner's hospital would be used in its home health agency to help assure high quality patient care.
Petitioner would also develop a utilization review plan similar to what is in effect at the hospital that would help insure proper utilization of the home health agency.
Petitioner is JCAH accredited and licensed by the State of Florida, and is currently in compliance with all State of Florida licensure requirements.
Petitioner's home health agency would be a hospital-based home health agency, as opposed to a free-standing home health agency.
There are benefits to being a hospital-based home health agency. The home health agency employees have the advantage of being part of the hospital's employment benefit package; the home health agency has the ability to tap into the expertise of the hospital in such areas as accounting, data processing, and so forth; discharge planning is easy to coordinate; and, the home health agency has the potential ability to use trained hospital personnel who have high tech skills and expertise and can provide services to the home health agency in their area of expertise. However, the suggestion that employees would be involved in both roles of hospital care and home health care is suspect in that certain employees such as nursing staff are not expected to fulfil that dual role and other employees such as the dietician were unable to consistently aid the patient in the home and carry out the duties in the hospital under an arrangement by which the Intervenor per agreement with the Petitioner sought to have continuation of services from the hospital to the home. If this could not be done, given the demands on the dietician in the hospital duties at that time, then there is no reason to believe that it would be any easier to achieve if the hospital had a home health agency. None of the aforementioned benefits are significant improvements over existing conditions in Citrus County where home health care is provided by freestanding agencies.
More specifically, Petitioner currently has physical therapists, respiratory therapists, dietitians, and social workers on its full-time paid staff that could conceivably be available to the home health agency. Since these persons are already full-time salaried employees of the hospital, it would not cost the home health agency any additional amount for these skilled persons to provide services to home health care patients, assuming the ability to meet the needs of hospital patients and home health care patients, again a real uncertainty.
Petitioner's personnel would be available to assist in the development of policy and procedure manuals, quality assurance plan and utilization review plan for the home health agency.
There are other possible economies in service that could be derived from Petitioner's operation of a hospital-based home health agency. These include: the hospital-based agency is easily accessible to physicians; discharge planning is facilitated due to the close cooperation of nursing, social worker, and home care provider while the patient is still in the hospital; services will be available 24-hours a day through the use of hospital switchboard and communications systems; and use of current medical records systems will mean a patient's entire medical history will be available to practitioners. Again, these arrangements do not afford a significant improvement over existing home health services.
Petitioner has sufficient resources available to initiate and operate a hospital-based home health agency. Necessary staff can be employed to the extent they are not already working at the hospital.
Petitioner is in sound financial condition.
Petitioner would be able to hire a qualified administrator.
Petitioner's projected payor mix of 88% Medicare, 3% Medicaid, 4% insurance and 5% indigent, is an admirable goal. However, there is some question about whether the projections of Medicare and indigent care levels of service will be achieved. Petitioner as a referral source from its hospital operations had not achieved those projected levels of referrals in the past. This is important because Petitioner expects to obtain its home health patients from the hospital referrals. Consequently to promote the grant of the CON premised solely upon the belief that underserved groups will be better off would not be warranted. The possibility exists that with greater awareness more underserved persons might be referred for home health care but nothing in this case points to any increased effort to publicize the availability of home health for the underserved to justify the optimistic levels the applicant predicts.
In a home health agency, all of the patient services are provided in the patient home. Thus, the only space requirement is for office space for the administrative staff and working space for the employees to do their necessary paperwork. Petitioner Memorial Hospital has about 1,600 square feet of vacant space available in which to house the home health agency offices. This building is currently owned by Petitioner. There is no debt associated with this building, and the building has been fully depreciated.
Contrary to the statement in its application, Petitioner has decided not to offer prescription delivery services. This is not a significant change.
Intervenor is a licensed home health agency in Citrus County. It first became licensed by the State of Florida in February, 1986.
Intervenor has been surveyed annually by Respondent since 1986. In each of these surveys, it received no deficiencies.
Intervenor is a full-service home health agency. It offers a range of "hi-tech" home health services, including: skilled nursing services; physical therapy; occupational therapy; speech therapy; social services; home health aide services; dietary guidance; medical supplies; home IV therapy; parenteral nutrition; interostomal therapy; home phlebotomy and lab testing services; and respiratory care. It has offered these services since its inception.
Intervenor provides some homemaker services during home health aide visits, such as cleaning, straightening, and laundry.
Intervenor's personnel include registered nurses, certified home health aides, physician therapists, licensed physical therapist assistants, speech therapists, occupational therapists, a medical social worker who holds a masters in social work, interstomal therapists, nutritionists, and respiratory therapists.
Intervenor offers quality of care and ensures continuity of care in the delivery of home health services.
Petitioner has never complained that a patient could not be discharged quickly enough due to Intervenor's shortcomings in taking on home health services for the discharged patient.
Intervenor makes every effort to coordinate its operations with Petitioner to ensure quality and continuity of care related to patients referred by the hospital.
The service area of Intervenor is Citrus County. Until late 1988, about 70% of Intervenor's referrals came directly from Petitioner.
On average, Intervenor provides about 28.6 home health visits per patient.
Intervenor provides home health services to all patients regardless of ability to pay. Intervenor provides home health services to the following payor classes: Medicare, Medicaid, VA, workmen's compensation, private insurance, and indigent. Its CON contemplates 2% Medicaid and 3% indigent patients.
Since opening in 1989, Intervenor has treated 985 patients. Of these 985 patients, only ten (10) have been indigent and fifteen (15) have been Medicaid patients. This works out to one percent (1%) indigent care and one and one half percent (1.5%) Medicaid care.
Community Care publishes a brochure that advertises its services to the community. Nowhere in this brochure does it indicate that Community Care serves indigent patients. The brochure stresses that services will be provided through reimbursed coverage, either Medicare, insurance, or other reimbursement sources. On the other hand it does not require any deposit or up-front payment from new home health patients and has never refused a patient due to an inability to pay.
As stated until recently a very substantial portion of the Intervenor's referrals came from Petitioner and levels of service to the underserved, that is, Medicaid and indigent, have been low. This ties back to the observation that the 3% Medicaid and 5% indigent projection of service made by Petitioner may not be any easier to achieve and probably less so than the 2% Medicaid and 3% indigent which Intervenor is committed to. This is supported by the fact that on the first 11 months in 1988, Petitioner referred less than 2% Medicaid and 1% indigent.
Moreover, the District III average for existing agencies of services to these underserved groups is .8% Medicaid and 1.3% indigent.
As alluded to before, in December, 1985, Petitioner and Intervenor entered into an agreement. Per that agreement, Petitioner would refer all home health patients to Intervenor unless a patient or physician specifically requested otherwise. The agreement provided that Petitioner would provide certain services and personnel to Intervenor in exchange for compensation. It was a two-year agreement with an automatic one-year renewal.
Petitioner chose to extend the contract for three years through the latter part of 1988.
Since late 1988, Petitioner rotates its hospital referrals in the instance where the patient, patient's family or physician did not specify which home health agency was preferred. This means that as many as seven agencies could be involved in the rotation if Petitioner gained a CON, with Petitioner having no greater share than the rest. At present, there are four providers, two in the rotation are from the ABC home health group, the Intervenor and Upjohn another home health provider. Petitioner would make five. To make seven, VNA and Gulf Coast Home Health Services who have come into Citrus County would be added. VNA is another provider with a history of service to underserved patients.
In this connection, Petitioner argues that its equal treatment of existing providers and itself, if granted a CON, minimizes the adverse impact of another competitor arriving on the scene and allows existing providers who are for profit agencies to remain financially viable. This together with trends toward early release in DRG for the hospital inpatient sector; provision of home health care through the Catastrophic Healthcare Act, and the general trend in increased home health visits in Citrus County make it possible for both the existing providers and the Petitioner to survive in the market place, if you accept the point of view of those who favor the grant of a CON to Petitioner.
In fact, the DRG situation and the Catastrophic Healthcare Act, as events, are too speculative to say what their influence will be in promoting greater use of home health services. Otherwise, the trend toward increased visits that have been pointed out are now being met with an increased number of providers to deliver those visits.
This dilutes market share. The Petitioner's rotation system further dilutes market share, especially as to the Intervenor. Thus, the question is raised on the matter of whether the historical trend toward increased visits is enough to sustain the existing providers with the advent of the Petitioner's presence and choice to rotate referrals. On the whole, the Petitioner's influence on competition is not positive and is not acceptable.
The Petitioner's projections concerning its own market acceptance are unrealistic and unacceptable. The projections in the original application and in the December 5, 1988 update to that application as to skilled visits per patient far exceed the experience in the service area, Citrus County. The applicant speaks in terms of 53 visits when the historical experience in the county is approximately 30. Nothing in the record of the hearing tends to support the idea that Petitioner can deliver such an excessive increase in visits. Additionally, estimates of total home health visits in the first two years of operation are generally out of line. The estimate by Petitioner ranges as high as 42,000, plus visits. Some of the items in that count are not comparable to referrals made out of the hospital at present. Examples of this incomparability are homemaker services, DME and the category listed as general items. Again, prescription service is no longer proposed thereby reducing the numbers. Nonetheless, the estimate is still excessive. This is made the more apparent when taking in account that by annualizing available data 464 patients were referred by Petitioner in 1988. In examining what had been referred out in 1988 in number of patients, the number of visits on average by history and the idea of rotation of referrals, Petitioner cannot achieve the performance level it predicts. Moreover, projections for population in 1990 and 1991, the furtherest years out given by Petitioner in support of its application, don't change this impression because the increases in population will not justify the Petitioner's projections on market share as a function of number of visits. The estimates of visits at 1990 and 1991 based upon 50% retention of referrals projected from Petitioner's hospital for home health services is unrealistic in that retention could be as low as 15% to 20%. Therefore, visits would be much less than 5,693 and 7,950 in 1990 and 1991, respectively. (See Petitioner's Exhibit 22.)
The failing in the estimate of performance level means that the revenue projections are inaccurate. Although Petitioner is a not for profit institution, its proposed home health operation is not seen to be financially feasible in the short term or long view. The fact that approximately 80% of costs in a home health operation are variable and that home health delivery is cost-based reimbursed does not relieve the Petitioner from giving a more
realistic estimate of those costs, its performance and net financial position. The effect of this failing leaves the record unclear and the trier of fact unconvinced concerning the true facts about this project's financial feasibility.
The pro formas as written do not identify employee benefits ranging in costs from 25% to 30%.
Transportation costs are not reflected.
If other facts were favorable to Petitioner, there would be very little additional costs associated with the start-up of its operation. Only minor "sprucing up" would be necessary before occupying existing space. Excess office furniture is currently available at the hospital.
The addition of Petitioner as a provider of home health services will not significantly advance variety or quality of care sufficient to justify the issuance of a CON. At present, existing providers offer a wide variety of home health services and provide quality care. The fact that the Petitioner is a hospital based not for profit institution, does not alter these findings.
The addition of Petitioner promotes no positive influence in competition in the market place. The risk is presented that overall cost in the health care system can be increased if the Petitioner is added and the market place becomes overburdened.
Based upon past experience, the Intervenor needs to achieve around 8,700 visits a year to be financially viable, and to break even. Petitioner's proposal together with other competitors in the market, some recently arrived, Upjohn, VNA and Gulf Coast Home Health Services jeopardize the ability to remain financially viable. Nothing can be done about the other competitors, but the issue of Petitioner's presence can be dealt with and should be rejected as an outcome.
At a minimum the addition of Petitioner does not foster cost containment in that it could cause the existing providers to up requests for reimbursement nearer the caps in the Medicare segment at public expense.
While there is a need for homemaker services in Citrus County, that fact doesn't justify the grant of a CON to Petitioner because it is willing to provide them.
In home health care delivery there is credible evidence that initial economies of scale occur between 6,000 to 9,000 visits per annum. There is a serious question about the Petitioner's ability to achieve that level of performance under the facts found previously.
When initially reviewing the compliance of the application with the 1986 District III Health Plan, in addition to problems of compliance with the need methodology in that plan, Petitioner did not respond to the need for home health services in Hamilton County and expansion of the range of services in Columbia and Suwannee Counties. These counties are within District III. These latter items concerning the other counties do not hinder the Petitioner's attempt to gain a CON because at present the decision to grant or deny a CON is on a district-wide and not county-by-county basis. Therefore, in theory, the Petitioner could serve Hamilton, Columbia and Suwannee Counties. Admittedly, that is unlikely given the proximity of these counties to Citrus County. More
importantly, there has been no showing that some other applicant entitled to comparative review with the Petitioner sought to serve the other three counties putting into effect the local planning guidelines on priorities for grant of a CON.
Likewise the local planning council methodology is of no moment. It deals with a county-wide analysis, not a district-wide analysis of need. The district-wide concept applies in this case per the change in the method of assessment that was fostered by the agreement to wait for the Respondent to enact a rule methodology and with that delay the tacit acceptance of the idea that approved and licensed home health providers could expand their services throughout the district. By contrast the fact that the local council reported that 148% of need was being met in Citrus County is telling and works against Petitioner.
Finally, the support of the application by the local council as advisor to the Respondent is noteworthy but cannot overturn the adverse facts in this hearing which cause the application to be rejected.
Petitioner is basically in compliance with the Florida State Health Plan in effect at the time of application except for the question of whether the Petitioner can achieve the aforementioned economies of scale at 6,000 to 9,000 visits per annum and the possible adverse influence on existing providers in maintaining economies of scale.
Rule 10-5.0111(1)(d), Florida Administrative Code, supra, is the product of a considerable effort by Respondent to establish a balanced method of measuring the need for additional home health care providers in the various districts throughout the state. Unfortunately, it has limited utility in trying to resolve this controversy.
The proponents of the use of the rule point out that nothing in the rule states that it cannot be applied retroactively to the case facts. Intervenor reminds us that nothing says it can be applied in that way. As hinted before, the rule cannot be seen to apply retroactively as it is written to render a defensible projection of need at the theoretical planning horizon of January, 1988.
First, the service area in December, 1986 through January, 1988 was in reality Citrus County, not the district. There is no way to postulate who might have taken advantage of the opportunity to serve the overall district and come into Citrus County from outlying counties within the district because that was not allowed as a matter of right back then as it is now in the terms of the rule. The present situation has shown that there is such interest in coming into Citrus County with the addition of Upjohn, VNA and Gulf Coast Home Health Services. Next, the idea of who would have been shown as approved as a home health agency taking into account the January, 1988 planning horizon cannot reasonably be ascertained. The annual fixed need pool publication did not occur such that one could see who had been approved, or held a CON, one month prior to that publication to serve the district. Although one could argue that the identification of the pool can be hypothetically set for the fall of 1986, problems with identifying the 1985 data to establish that pool based upon information that was available to the Respondent at the time to announce the pool or availability of a complete data set about 1985 at the point of hearing persist. Associated with this dilemma is the influence agency expansions into other counties would have on calculation of CEAS. In the area of CEAS the exact nature of that situation cannot be ascertained. It cannot because one doesn't
know which existing providers might have determined to go out of the counties in which they had offered their services and into other counties to open new units. This would have some influence on the average agency size within the district, which in turn causes a possible different answer in deriving the number of needed providers by the use of the formula. All this makes the exercise of accurately setting the pool unlikely and it wasn't done in this hearing.
In using the district-wide service analysis back in time to fit the Petitioner's situation, an application by VNA in District III, Alachua County, pending and denied in December, 1987, the same month as Petitioner's denial, was not comparatively reviewed with the Petitioner as the law would theoretically require. VNA was subsequently approved and is functioning now. Consequently, comparative review is no longer possible.
On the topic of the 1985 data, which is mandated in exercising the rule, what data in this category was available in the fall of 1986 is uncertain. The data about 1985 presently held by the Respondent is incomplete. This incompleteness is in AHAV where visits in all categories cannot be shown for 1985. This tends to understate what the formula derives as an answer. The derived answer for needed agencies is .7, rounded up per terms in the rule is one agency if the other factors that were described are ignored. They should not be. Especially, compelling is the existence of VNA, Alachua County which could use up the net need of one agency.
Concerning the applicants who waited for the Respondent to enact a rule who applied for a CON in the period June, 1985 through December, 1987, the Respondent modified the use of the rule. In its thinking to make certain that no applicant along that time continuum was treated unfairly, Respondent picked 1986 data and a July, 1988 planning horizon in deciding the question of need. The result in the Petitioner's case was to use inappropriate data and an inappropriate planning horizon, according to the rule. This produced an answer of 1.1 agencies rounded down to 1. This is the same answer as before and no purpose is served in criticizing the Respondent's choice to deviate from the terms of the rule.
On balance the concept of this rule as opposed to the ability to use the rule per se may look appealing as an abstraction, but it is unappealing as a means to resolve the factual dispute. It superimposes a system of district review at a time of county level service. For that reason, it cannot answer the riddle of how many providers would have exercised the right to serve Citrus County from other counties in the district as they have begun to do when the rule took effect in September, 1988. Using the rule retroactively anticipates a planning horizon which is already past. In recognition of this anomaly the parties have spoken to the future in their proof through the years 1990 and 1991. This has been necessitated by the agreement to wait for the Respondent to enact a new home health rule. That future is not conducive to the grant of the CON on the facts in this case which are more instructive about the true need in the district than the exercise of the formula in some past period. Had the Petitioner chosen to reapply and fallen under the clear terms of the rule, the result might be different. It did not, and it must accept the results of that choice.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the subject matter and the parties in accordance with Section 120.57(1), Florida Statutes and Section 381.709(5)(b), Florida Statutes.
Petitioner bears the burden of establishing its entitlement to the CON that it has sought through this application process. See Florida Department of Transportation v. J.W.C. Co., Inc., 396 So.2d 778 (Fla. 1st DCA 1981) and Boca Raton AKC v. Department of Health and Rehabilitative Services, 475 So.2d
260 (Fla 1st DCA 1985). In measuring that proof, reference is made to the applicable criteria within Section 381.705, Florida Statutes. In deciding the issue of compliance with the applicable provisions within Section 381.705, Florida Statutes, a balanced approach is utilized with varying degrees of weight being afforded those criteria, depending on the facts of each individual case. See Department of Health and Rehabilitative Services v. Johnson & Johnson Home Health Care, 447 So.2d 361 (Fla. 1st DCA 1984) and Collier Medical Center, Inc.
v. Department of Health and Rehabilitative Services, 462 So.2d 83 (Fla. 1st DCA 1985). Petitioner must also demonstrate its compliance with the state health plan and local health plan in effect at the time of the application in December, 1986. Petitioner has failed in this proof.
Section 381.705(1)(a), Florida Statutes, measures this application on the basis of, "the need for the health care facilities and services and hospices being proposed in relation to the applicable district plan and state health plan."
The state health plan speaks in terms of promotion of competition in the manner consistent with reasonable economies of scale. The facts in this case do not indicate that the Petitioner would achieve reasonable economies of scale and present the possibility that the addition of Petitioner threatens economies of scale for existing providers. That is to say, that the number of visits for those existing providers may be reduced below the point of economies of scale. To this extent, the Petitioner has not complied with the state plan.
The local plan was drawn at a time when county-wide review was the order of the day and not district-wide. The methodology that was utilized under that plan was a county-wide concept. District-wide view is contemplated in this instance and the methodology in the local plan has no value. Likewise, emphasis on the placement of a provider in Hamilton, Columbia and Suwannee Counties in a district-wide concept in which a provider asking to offer services in those areas was not forthcoming in the review cycle associated with the Petitioner, leads to the conclusion that this idea of priorities is inapplicable on this occasion. On the other hand, the suggestion that 148% of the need in Citrus County was being met is a telling fact when considered in the context of other facts pointing to the lack of need for an additional home health provider in the Citrus County area.
The significance of this information concerns the idea that while district-wide review is called for, it is the area of Citrus County and its immediate environs within the district that has meaning. This is based upon the recognition that Home Health provider in this sixteen county area is not going to serve every county given that some areas within the district are too remote to expect to receive home health visits from the Petitioner's offices.
Section 381.705(1)(b), Florida Statutes considers the question of, "the availability, quality care, efficiency, appropriateness, accessibility, extent of utilization, and adequacy of like and existing care services and hospices in the service district of the applicant." In this circumstance for reasons as set out in the fact finding, Petitioner does not meet that criterion in that there are available providers who offer available quality care, and efficient appropriate and accessible home health services that are not over
utilized and who can offer the same scope of services contemplated by the Petitioner.
Section 381.705(1)(c), Florida Statutes is a criterion that speaks to, "the ability of the applicant to provide quality of care in the applicant's record of providing quality of care." If there were a need for the Petitioner's services, it would meet this criterion. However, that need does not exist.
Section 381.705(1)(d), Florida Statutes is a criterion that examines this application on the basis of, "the availability and adequacy of other health care facilities and services and hospices in the service district of the applicant, such as outpatient care and ambulatory or home care services, which may serve as alternatives for the health care facilities and services to be provided by the applicant." Again, existing providers meet the need and the Petitioner's participation would promote an unacceptable redundancy in services.
Section 381.705(1)(e), Florida Statutes as a review standards deals with, "probable economies improvement and improvements in service that may be derived from operation of joint, cooperative, or shared health care resources." While it may be argued that the relationship between the hospital and a home health service housed within its basic facility and with patient records and staff input being readily accessible is an attractive arrangement, nothing in the facts pertaining to this case suggests marked improvement in the conditions that now exist in which the continuity of care between hospital treatment and home health assistance has been maintained at a high level.
In addition, any joint or cooperative or shared care services that could be done in-house between the hospital and its home health arm could be as readily achieved between the hospital and some existing home health provider independent of the hospital.
Sections 381.705(1)(f) and (g), Florida Statutes, do not apply.
Section 381.705(1)(h) as a review standard states:
(h) The availability of resources, including health manpower, management
personnel, and funds for capital and operating expenditures, for project accomplishment and operation; the effects the project will have on clinical needs of health professional training programs in the service district; the extent to which the services will be accessible to schools for health professions in the service district for training purposes if such services are available in a limited number of facilities; the availability of alternative uses of such resources for the provision of other health services; and the extent to which the proposed services will be accessible to all residents of the service district.
Petitioner has the available resources to accomplish this project but its resources are better spent. It would make its services available to all residents of the service district.
Section 381.705(1)(i), Florida Statutes, speaks to the immediate and long-term financial feasibility of the proposal. This proposal is not a feasible, financially viable arrangement either in its immediate or long-term plan.
Sections 381.705(1)(j) and (k), Florida Statutes, do not apply to this base.
Section 381.705(1)(l) Florida Statutes, as a criterion for review states:
The probable impact of the proposed project on the costs of providing health services proposed by the applicant, upon
consideration of factors including, but not limited to, the effects of competition on the supply of health services being proposed and the improvements or innovations in the financing and delivery of health service which foster competition and service to promote quality assurance and cost-effectiveness.
The impact of this project on cost of providing health services is not positive. The impact of this project will not spawn a desirable result as a competitor in supplying health services and will not bring about improvements or innovations in the financing and delivery of those health services in fostering competition and service to the public. The project adds nothing significant in terms of quality assurance and cost effectiveness. In fact, it is not a cost- effective project. The competitive environment already exists in this area contemplated for service by the Petitioner. If anything, Petitioner will have an adverse effect on that competition by presenting the risk of additional cost in health care related to the possibility of increased rates of reimbursement in order to allow providers in the market place sufficient profit margin to remain financially viable.
Section 381.705(1)(m), Florida Statutes talks about "the cost and methods of the proposed construction, including the cost and methods of energy provision and the availability of alternative, less costly, or more effective methods of instruction." There is no real construction involved in this circumstance. Nonetheless, to the extent that this provisions has application, Petitioner has proposed a very cost-efficient headquarters for its operation.
Section 381.705(1)(n), Florida Statutes, speaks in terms of the "applicant's past and proposed provision of health care services to Medicaid patients and the medically indigent." Petitioner is dedicated to meeting the needs of those patients and could be expected to do so on this occasion. However, the proposed levels of service to those individuals may not be achievable and should not constitute a basis for the grant of this CON.
There remains the question of the applicability of Rule 10- 5.011(1)(d), Florida Administrative Code. The proponents of the use of this Rule refer to the decisions of Turro v. Department of Rehabilitative Services,
458 So.2d 345 (Fla 1st DCA 1984) and Balsam v. Department of Health and Rehabilitative Services, 486 So.2d 1341 (Fla. 1st DCA 1986), as well as Department of Health and Rehabilitative Services v. Johnson, supra, as standing for the proposition that the rule should have application. Notwithstanding the holdings in these cases, the rule does not apply. The parties upon agreement
decided to wait for the agency to pass the rule before proceeding to hearing. That choice was made with the expectation that guidance would be provided through the passage of a rule that would be beneficial in resolving this conflict. For reasons that have been explained in the factual discussion, the rule cannot be seen to have application. Although it does not specify in exact terms whether it is intended to have retroactive application or not, a fair reading leads to the conclusion that it is not applicable. It has the problem in trying to use it in the past of fitting a real fact circumstance that saw the usage of county-wide service areas as opposed to district-wide service areas, that presents difficulty in determining what data has application in utilizing the rule, in not really having a fixed need pool, in acknowledging VNA Alachua County as a comparative review competitor and ;the advent of providers from outlying counties. See Biomedical Applications of Clearwater, Inc. v.
Department of Health and Rehabilitative Services, 370 So.2d 19 (Fla. 2d DCA 1979). At present, the mechanical use of the rule even assuming the correct data can be gathered and the intellectual problem of overcoming the fact that the fixed need pool was never announced, does not deal satisfactorily with the fact that district-wide review was in order. One can never remedy the failure to comparatively review the VNA Alachua County application with that of the Petitioner, nor can one deal adequately with the issue of how many other providers would have come into Citrus County at an earlier date than has actually occurred had they had the opportunity to do so from the inception of the application process in 1986 related to this Petitioner. It can also be seen that the place and time of the applicable planning horizon in terms of the rule, maintaining the review cycle associated with this applicant's filing date, January, 1988 has passed. There was adequate service being provided at that point. That is a matter of fact. The artificial use of the rule to give some contrary impression is irrational.
Petitioner is ultimately left with the ability to have its case considered with the peculiar facts that are associated with this case. Upon that analysis, the CON should not be granted. Alternatively, the only choice which the Petitioner had was to utilize the rule's terms in a prospective way by refiling its application in search of a different planning horizon which it did not elect to do. See Gulfcourt Nursing Center v. Department of Health and Rehabilitative Services, 438 So.2d 700 (Fla. 1st DCA 1985) and NME Hospital, Inc. v. Department of Health and Rehabilitative Services, 492 So.2d 379 (Fla. 1st DCA 1985)
The request to strike certain factual references in the Petitioner's proposed recommended order is moot in that the recommended order has attended that matter through fact finding.
Based upon a consideration of facts found in the conclusions of law reached, it is,
RECOMMENDED:
That a final order be entered which denies the request for Certificate of Need as applied for by Petitioner.
DONE AND ENTERED this 29th day of June, 1989, in Tallahassee, Leon County, Florida.
COPIES FURNISHED:
Sam Power, Clerk Department of Health
and Rehabilitative Services 1323 Winewood Boulevard
Tallahassee, FL 32399-0700
Gregory L. Coler, Secretary Department of Health
and Rehabilitative Services 1323 Winewood Boulevard
Tallahassee, FL 32399-0700
Stephen K. Boone, Esquire Boone, Boone, Klingbell
Boone & Roberts, P.A. 1001 Avenida Del Circo
P. O. Box 1596 Venice, Florida 34284
Stephen M. Presnell, Esquire Macfarlane, Ferguson, Allison
& Kelly
Post Office Box 82 Tallahassee, Florida 32302
James C. Hauser, Esquire Joy Heath Thomas, Esquire Messer, Vickers, Caparello,
French & Madsen, P.A.
O. Box 1876 Tallahassee, Florida 32302
CHARLES C. ADAMS
Hearing Officer
Division of Administrative Hearings The DeSoto Building
1230 Apalachee Parkway
Tallahassee, Florida 32399-1550
(904) 488-9675
Filed with the Clerk of the Division of Administrative Hearings this 29th day of June, 1989.
APPENDIX TO THE RECOMMENDED ORDER IN CASE NO. 88-0386
The following discussion is given concerning the proposed facts of the parties.
Petitioner's Proposed Finding of Facts
The first paragraph and the first sentence to the second paragraph are subordinate to facts found. The remaining sentences within paragraph 2 are not necessary to the resolution of dispute.
Paragraph 3 is contrary to facts found.
Paragraphs 4-7 are subordinate to facts found with exception the last sentence in paragraph 7 which is contrary to facts found.
Paragraph 8 is subordinate to facts found.
Paragraph 9 may express the statement of policy by the Respondent, but it is not an acceptable outcome in this instance.
Paragraphs 10-12 are subordinate to facts found.
Paragraph 13 is an accurate portrayal of the facts as far as its goes; however, it does not account for the problems of imposing the new home health rule over the time period associated with the filing date in this application.
Paragraphs 14-16 are subordinate to facts found.
Paragraph 17 is contrary to facts found.
Paragraph 18 is subordinate to facts found.
Paragraph 19 is not necessary to resolution of dispute.
Paragraph 20 in all sentences except the latter is subordinate to facts found. The latter sentence is not necessary to the resolution of dispute.
Paragraph 21 is subordinate to facts found.
Paragraph 22 is contrary to facts found.
Paragraph 23 is subordinate to facts found.
Paragraph 24 is contrary to facts found.
Paragraph 25 is true in that at the time the local health council examined the application there was an indicated need for home health for Medicare and indigent patients. That need is being met at present to the extent that those classes of patients have been made aware of the existence of the home health services.
Paragraph 26 is subordinate to facts found.
Paragraphs 27 and 28 are contrary to facts found.
Suggestions in Paragraph 29 do not comport with the situation in Citrus County at present.
Paragraph 30 is subordinate to facts found.
Paragraph 31 is contrary to facts found.
Paragraphs 32-36 are subordinate to facts found.
Paragraphs 37 and 38 are not necessary to the resolution of dispute.
Paragraphs 39-43 are subordinate to facts found.
Paragraph 44 is not necessary to the resolution of dispute.
Paragraphs 45-51 are subordinate to facts found.
Paragraph 52 is not necessary to the resolution of dispute.
Paragraph 53 is subordinate to facts found.
Paragraphs 54-56 are contrary to facts found.
Paragraph 57 is subordinate to facts found.
As to Paragraph 58 it is uncertain whether the staff levels are adequate given the failure to accurately portray the volume of visits.
In a related sense, Paragraph 59 as to salary level made to depicts the cost of those salaries, but it fails to include the benefits.
Paragraph 60 is to general in its contention. It does not answer the failure to identify the more reasonable statement of staffing levels.
Paragraph 61 is subordinate to facts found. The pro formas were not clear and the complementary proof offered at hearing did not confirm the assertion set out in paragraph 62.
Paragraphs 63-65 are contrary to facts found.
Paragraph 66 is subordinate to facts found.
Paragraph 67 is contrary to facts found.
Paragraph 68 is not necessary to the-resolution of dispute.
Paragraph 69 depicts a situation that is to speculative to have relevance in this case.
Paragraphs 70 and 71 are contrary to facts found.
While the Paragraphs 72-74 accurately states the circumstance related to the intervenor in its initial involvement in the market. This situation has changed since that time and if Petitioner were to gain entry into the market the probability is that the intervenor's business would be seriously impacted.
Paragraph 75 is contrary to facts found.
Paragraphs 76 and 77 are subordinate to facts found.
Paragraph 78 is not necessary to the resolution of dispute.
Paragraphs 79-82 with exception of the last sentence in 82 are subordinate to facts found. The last sentence in paragraph
82 is not accepted.
Paragraph 83 is subordinate to facts found.
Paragraphs 84 and 85 are contrary to facts found.
Paragraph 86 is true if one fails to take into account the advent of services by the intervenor and additional providers who has come into the market who are willing to undertake service to those patients.
Paragraphs 87 and 88 are contrary to facts found.
Paragraph 89 is subordinate to facts found.
Paragraphs 90 and 91 are contrary to facts found.
Paragraph 92 is subordinate to facts found.
In Paragraph 93, while it is true that Petitioner has an excellent record of service to the Medicaid population in Citrus County, it is unclear why Medicaid patients are not receiving sufficient home health services, compared to what one would expect the demand to be.
Respondent's Proposed Findings of Fact
Paragraphs 1-3 are subordinate to facts found.
Paragraphs 4-6 are contrary to facts found.
Suggestion in Paragraph 7 is not a certainty and is not accepted in the fashion presented in these proposed facts.
Paragraphs 8-10 are contrary to facts found.
Paragraph 11 is subordinate to facts found.
Paragraph 12 is contrary to facts found.
Paragraphs 13 and 14 is subordinate to facts found.
Paragraph 15 is a true statement if other factors which have
been discussed in the recommended order are not taken into account.
Paragraph 16 is subordinate to facts found.
Paragraph 17-19 are not sufficiently relevant to this case to be reported as facts.
Paragraph 20 is contrary to facts found.
Paragraph 21 is subordinate to facts found.
Paragraphs 22 and 23 may be basically an accurate statement of the Respondent's policies; however, this arrangement is not satisfactory on this occasion.
Paragraph 24 is subordinate to facts found.
Paragraph 25 is contrary to facts found.
Paragraph 26 is subordinate to facts found.
Paragraphs 27 and 28 are not necessary to the resolution of dispute.
Paragraph 29 is subordinate to facts found.
Paragraph 30 is true if the rule was found to be applicable.
Paragraph 31 and 32 are not necessary to resolution of dispute.
Paragraph 33 may be true in terms of the prospective use of the rule but is not influential in this case.
Paragraph 34 is not necessary to the resolution of dispute.
Paragraph 35 is speculative and has little relevance absent a showing that the expansion into the other areas within the district offset new providers coming into Citrus County, to include the Petitioner.
Paragraphs 36 and 37 are subordinate to facts found.
The suggestion in paragraph 38 is a statement of limited value in that there are no other competitors in District III from other batches.
Paragraphs 39-43 are subordinate to facts found.
The first sentence to paragraph 44 is subordinate to facts found. The remaining sentence is contrary to facts found.
Paragraphs 45 and 46 are subordinate to facts found.
Paragraph 47 is contrary to facts found.
Paragraph 48 is accurate as for as it goes; however, it fails to take into account the fact that the Intervenor began to provide home health care to indigent and Medicaid patients.
Paragraph 49 is contrary to facts found.
Paragraph 50 is subordinate to facts found.
Paragraph 51-53 are contrary to facts found.
Paragraph 54 is subordinate to facts found.
35 The suggestion in the first sentence of paragraph 55 is true. Again it fails to take into account the change in circumstances with the advent of the Intervenor's services. The second sentence is subordinate to facts found.
Paragraph 56 is not in meaningful contribution to the fact finding in the context of the overall facts reported in the recommended order.
Paragraphs 57 and 58 are subordinate to facts found.
Intervenor's Proposed Findings of Facts
Paragraph 1 is subordinate to facts found.
Paragraph 2 is not necessary to the resolution of the dispute.
Paragraphs 3-5 are subordinate to facts found.
Paragraph 6 is not necessary to the resolution of the dispute.
Paragraph 7 is subordinate to facts found.
Paragraph 8 is; not necessary to the resolution of the dispute.
Paragraphs 9 through the first sentence in paragraph 16 are subordinate to facts found. The remaining sentences in paragraph
16 are not necessary to the resolution in dispute nor is the first and last sentences within paragraph 17.
The other sentence within paragraph 17 is subordinate to facts found.
The first sentence in paragraph 18 is subordinate to facts found. The remaining sentences are not necessary to the resolution of the dispute.
Paragraphs 19 through the first sentence of paragraph 23 are subordinate to facts found. The second sentence in paragraph 23 is not necessary to the resolution of the dispute nor is paragraph 24.
Paragraph 25 in all sentences save the last is subordinate to facts found. The last sentence is not necessary to resolution of dispute.
Paragraph 26 through all sentences in paragraph 30 except the last sentence are subordinate to facts found. The last sentence is not necessary to the resolution of the dispute.
The first sentence of paragraph 31 is subordinate to facts found. The remaining sentence is not necessary to the resolution of dispute.
Paragraph 32 and the first sentence to paragraph 33 are subordinate to facts found. The remaining sentence in paragraph
33 is not necessary to the resolution of dispute.
Paragraph 34 and the first sentence of paragraph 35 subordinate to facts found.
The last sentence in paragraph 35 is not necessary to the resolution of the dispute.
Paragraph 36 through the first sentence of paragraph 38 are subordinate to facts found. The remaining sentence in paragraph
38 is not necessary to the resolution of dispute.
Paragraph 39 cannot be utilized in that the rule in question was not provided to the Hearing Officer under official recognition and is unavailable to confirm the assertion set out in that paragraph.
Paragraphs 40 through 43 are subordinate to facts found.
The suggestions in paragraphs 44 through 45 are contrary to the impression of the Hearing Officer.
Paragraphs 46 through 48 are subordinate to facts found.
Paragraphs 49 and 50 are not necessary to the resolution of dispute.
Paragraphs 51 and 52 are subordinate to facts found.
Paragraphs 53 through 55 as an approach to resolving factual disputes are rejected.
Paragraph 56 is subordinate to facts found.
Paragraph 57 is contrary to facts found.
Paragraph 58 is not in keeping with the analysis of this case and the facts found in the recommended order nor is paragraph 59.
Paragraphs 60 through 65 are subordinate to facts found.
Paragraph 66 is not necessary to the resolution of dispute.
Paragraph 67 and the first two sentences within paragraph 68 are subordinate to facts found. Remaining sentences within paragraph 68 are not in keeping with the analysis performed in the fact finding within the recommended order.
Paragraph 69 is subordinate to facts found.
Paragraph 70 is subordinate to facts found.
Paragraph 71 is not necessary to the resolution of dispute.
Paragraphs 72 through 76 are subordinate to facts found.
Paragraph 77 is not necessary to the resolution of dispute.
Paragraphs 78 and 79 are subordinate to facts found.
Paragraph 80 is not necessary to the resolution of dispute.
Paragraphs 81-86 are subordinate to facts found.
Paragraph 87 is not necessary to the resolution of dispute.
Paragraph 88 is subordinate to facts found.
Paragraphs 89-91 are not necessary to the resolution of dispute.
Paragraphs 92 through 94 are subordinate to facts found.
Paragraph 95 is not necessary to the resolution of dispute.
Paragraphs 96 through 101 in the first sentence to that paragraph are subordinate to facts found. The remaining sentences in paragraph 101 are not necessary to the resolution of dispute.
Paragraph 102 is subordinate to facts found.
Paragraph 103 is not necessary to the resolution of dispute.
Paragraphs 104 and 105 are subordinate to facts found.
Paragraph 106 is contrary to facts found.
Paragraph 107 is not necessary to the resolution of dispute.
Paragraphs 108 through 116 are subordinate to facts found.
Paragraphs 117 and 118 are not necessary to the resolution of dispute.
Paragraphs 119 through 122 are subordinate to facts found.
Paragraph 123 is not necessary to the resolution of dispute.
Paragraphs 124-126 are subordinate to facts found.
Suggestion in paragraph 127 that the rotation system will not be employed is rejected. The remaining contents within that paragraph are subordinate to facts found.
Paragraph 128 is not necessary to the resolution of dispute.
Paragraphs 129 through 133 are subordinate to facts found.
Paragraph 134 is contrary to the facts found.
Paragraph 135 is contrary to the facts found.
Paragraph 136 is not necessary to the resolution of dispute.
| Issue Date | Proceedings |
|---|---|
| Jun. 29, 1989 | Recommended Order (hearing held , 2013). CASE CLOSED. |
| Issue Date | Document | Summary |
|---|---|---|
| Aug. 22, 1989 | Agency Final Order | |
| Jun. 29, 1989 | Recommended Order | Passage of a home health rule after the application was filed but before hearing not controlling. Case decided on its peculiar facts. |
